Bombard, Pamela Ruth tizO
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Pamela Ruth Bombard Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/12/2021 79 Years War or Dates
F Place of Death Hospital,Institution or
WCity,Town or Village Kingsbury Town Street Address 916 Vaughn Rd,Kingsbury Town,New York 12839
`p Manner of Death 0 Natural Cause ❑Accident ElHomicide Suicide Undetermined Pending
LI
V Circumstances Investigation
Q Medical Certifier Name Title
John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Kingsbury Town 5762 9
Burial Date Cemetery,Crematory or Facility Name
05/14/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
0 Removal Date Place Removed
and/or and/or Held
l—
N Hold Address
0
d Date Point of
U) ❑Transportation
p by Common Shipment
Carrier Destination
0 Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
FE Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/14/2021 Registrar of Vital Statistics Cynt1iaf7Bar&n(rElectronicafS01ed)
(signature)
District Number 5762 Place Kingsbury Town, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF-
Z Date of Disposition s in iti Place of Disposition , jjL,
2 (address)
W
U)
CC (section) (lot number) (grave number)
SName of Sexton or Person in Charge of Pre s ^►1\ 11
Z (pleas riot) /�
W Signature ti, Title L f 'N
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) 0 w 4 7 8
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#